Brave Girl Eating_A Family's Struggle with Anorexia

chapter six

September

Through all my growing up, and through all my marriage and through all the tough times, I was always trying to measure up, or trying to be somebody else. And all of a sudden you said, “I just love you. I don’t need you to be well. It doesn’t matter.”
—BETSY HALL, who has struggled with anorexia and bulimia for much of her life, quoted in a film made by her daughter, Hope Hall
To mark the end of the first week of school—a week that’s gone pretty well for both Kitty and Emma—Jamie and I make plans for Sunday afternoon. We’ll take our kayaks to a nearby lake and paddle around, then hang out in the park onshore. Our last family outing was the opera in the park concert back in July. The night Kitty ended up in the hospital.
We’ve avoided going out since then because Kitty has needed to stay close to home. Eating is beginning to seem easier, but the prospect of eating a meal in front of other people still sends her into a panic. And I’ve come to realize just how much socializing is based around eating. Every party and backyard get-together includes food, and even when the focus isn’t a meal—say, a graduation party, even a neighborhood meeting—food is almost always on the table, literally and metaphorically. I think of Shan Guisinger’s comment about how social pressure facilitated eating in primitive societies and wonder if the urge to share food is an instinct coded into human DNA because it helps us build community.
Community, in any case, is the last thing on Kitty’s mind. Truly, I think she’s grateful to have homework, glad to have something else to think about, even if it is algebra. Maybe because it’s algebra, which is completely unconnected with anorexia. What makes school hard for her is what she used to love most about it: the friendships. She obsesses over what people think of her and is convinced they’re judging her because she has anorexia. I tell her no one blames her, that people understand she’s ill, that they feel empathy and compassion. I wish I believed that. I’m sure her closest friends do feel for her. But I’m also sure she is being judged, and harshly, by plenty of others. I know we’re all being judged, and found wanting, by some of the people who smile and cluck sympathetically in the grocery store, in the neighborhood, at the office or school. I know it hurts Kitty, because I know how much it hurts me, and Jamie, and even Emma.
We all have our reasons for staying close to home.
Kitty objects strenuously to the Sunday plan, and I nearly say never mind. But I feel as though that would be giving in to the anorexia, validating on some level her worries about—about what? I’m not really sure. So we load up our picnic, tie the kayaks onto the roof of the car, and go.
Lunch at the park takes more than an hour; Kitty dawdles and picks at her sandwich, insists she can’t eat the chips, tries to refuse the chocolate milk. I wonder again if this is a mistake. But we’re only five minutes from home; we can always leave if we have to.
Once we actually get into the kayaks, though—Jamie and Emma in a rented double, Kitty and I each in our own—it’s as if some switch gets flipped and Kitty is her old self, smiling, enthusiastic, even cracking a joke about my less-than-stellar steering skills. We paddle in loose formation under a watercolor-blue sky, waving at other boats, watching a muskrat swim away from our wake. Emma, too, seems more relaxed than usual. For the first time in months I remember the ways we all fit together. We share a sense of humor. We are a family.
Which is why it’s such a shock to see the demon emerge the very second Kitty steps out of the kayak. “I’m so fat,” she starts. “I’m horrible and no one loves me. Why doesn’t anyone love me?” When I try to calm her down, she accuses me of speaking harshly. She tells me I’m not listening to her feelings. The monotonous ranting of the demon goes on and on. Emma puts her hands over her ears, and Jamie walks her toward the car, dragging two of the kayaks with them. I give up talking to Kitty and just stay with her, on an isolated bench, until she winds down.
We walk up to the playground, and I give Kitty and Emma each a protein bar. We’ve learned the hard way that she has to eat something, even a small snack, every two hours or so; she’s gained eight or nine pounds, but her body still has no reserves. We feed her as often as you’d feed an infant.
I’m expecting resistance, but Kitty opens the wrapper and begins to eat. She takes tiny bites and chews each one with infinite care, the way she eats everything now. But at least she’s eating.
Jamie looks at me quizzically—What happened?—and I shake my head: Tell you later. Emma finishes her snack and runs over to the swings. Kitty stands up abruptly and starts toward the garbage can.
“What are you doing?” I call.
“I’m done!” she answers, not turning around. “I’m throwing away the wrapper.”
“Please come here,” I say, raising my voice so she’ll hear me. I don’t know why I want her to come back. I just do.
She turns, reluctantly, and walks toward me, one hand closed behind her back. “Show me,” I say, and even so, I’m shocked when she uncurls her fist and reveals half the protein bar, uneaten.
My daughter is fourteen years old and this is the first time I know of that she’s tried to deceive me. I feel like I’m watching the scene from a great distance as it happens to someone else. Kitty’s always been the good-girl type, afraid to break the rules or get into trouble. I know she’s lied before; every kid does. But this feels different. This isn’t Kitty.
She sits down beside me on the bench, folds back the paper, and begins to eat again. She keeps her eyes cast down and her face empty. What is she feeling? Is she angry or embarrassed, frustrated or defiant? She looks like a sleepwalker—blank, quiet, driven by some force deep within her.
For the first time it occurs to me that my daughter will be permanently changed by this—this thing inside her, this twisted creature that shrieks and writhes and spits poison into her blood and bone and mind. And that, in fact, each one of us will be changed, Jamie and Emma and I. Our family will never be the same. Even if Kitty gets well—and at this moment that seems a distant possibility—things will never go back to the way they were.
Of course this is always true, in every family, all the time. Children are walking palimpsests, continuously evolving, and as parents we change along with them, accommodating and responding to who they are in the process of becoming. Part of the pleasure and reward of parenting is watching the alchemy of childhood, seeing our offspring transform themselves from generic infancy into gloriously individual adulthood. And part of our necessary sorrow as parents is having to accept the kinds of change we fear for our children.
That night in bed, I say to Jamie, “Maybe we’ve hit the bottom now, and there’s nowhere to go but up?”
“Maybe,” he says.
We are, of course, wrong again.
The next morning Kitty comes down to breakfast with her hair in pigtails, a style I haven’t seen her wear in years. She dawdles at breakfast, stirring her bowl of granola and yogurt for twenty minutes, until I say, “You’re going to be late for school.”
“I’m not going,” she says.
“Why not?”
“Everyone there thinks I’m a freak who got fat over the summer. They won’t stop looking at me.”
“Who’s looking at you?” I ask.
“Everyone,” she says impatiently, and I wonder if this is normal teenage impatience or eating-disordered impatience. I hate the fact that I wonder about this. This is another legacy of anorexia: the need to question, analyze, worry every interaction like a dog with a bone. When all I want is to be like we used to be, Kitty and I, easy with and on each other.
I tell her I think she should go and at least try to stick it out. I tell her it’s only two morning subjects, and if she starts missing classes this early in the year, it will be hard to catch up, and that will feel even more stressful. I tell her (though I doubt she can take this in) that it’s important for her to stay involved with the world as much as she can. I know that if we let her stay home today, she’ll want to do it again tomorrow and the next day.
My words seem to have no effect. So I coax her up from the table after she’s eaten. “Come on, I’ll walk you,” I say.
I have to practically drag her out the door, into the steamy late summer air. I figure once we’re outside, her aversion to public scenes will make things easier. But this morning Kitty doesn’t seem to mind making a scene. She wrenches her arm out of my grasp and balks like a horse who’s come up against a jump too high. “Why are you torturing me?” she shouts, standing in front of our next-door neighbor’s house. “Why don’t you understand that I can’t go to school this morning?”
I speak in a low, soothing tone. “Come on, Kitty, you know you have to go,” I say and try to somehow urge her down the street without actually touching her.
She glares. “Why are you doing this to me?” she shouts, her voice rising to an actual scream on the last word. I consider taking her back inside—how can she possibly go to school like this? But my gut tells me that to back down now would be to let the demon win. I’m not letting this illness take one more thing from Kitty if I can help it. She’s suffering now, I know, but her whole life is at stake. We can’t go backward, even for a second.
And so I take hold of her arm again, firmly, and try to move her down the block, one step at a time. Two doors down from our house she sits down abruptly on the sidewalk, her short black skirt flipping up for a moment around her waist. I’m sure the neighbors are watching, not that I care; I’m not easily embarrassed. But Kitty is, and she would care, if she could process anything but the anxiety and terror overwhelming her.
By the time we get to the school she’s fifteen minutes late, which normally would freak her out; today I’m not sure she even notices. Clearly she can’t go to her first class. Last week, we met with the school psychologist, Mr. R., an earnest young man who told Kitty she was welcome in his office anytime, even in the middle of a class. Now I tell her I think she should go to Mr. R.’s office.
She whirls toward me with a look of pure rage, her pigtails bouncing incongruously. “The minute you leave I’m going to the bathroom to make myself throw up!” she yells.
Inside my head a voice is shouting No! No! No! I’ve read enough to know that up to 30 percent of people with anorexia cross over into bulimia, and that purging complicates recovery even more. It’s the last thing Kitty needs.
What should I do? Take her home? Follow her to class and keep her out of the bathroom all morning? I’m paralyzed. Kitty makes the decision for me. Standing in the empty hallway, she says, “Fine, I’ll go to Mr. R.’s office!” Then she’s running down the hall away from me, her backpack slapping against her shoulders. She rounds the corner and disappears. I have no idea which way Mr. R.’s office is, so I don’t know if she’s heading there or not. I stand there, irresolute. Eventually I walk home.
I spend the rest of the morning cleaning, unable to concentrate on anything else, picturing Kitty in the girls’ bathroom at school, a finger down her throat, or running out the door, away from school. Running away from us. In a school of several thousand, no one would notice she was gone.
I finally unclench my jaw when I hear the front door open at the usual time. Kitty seems calmer than when I left her at school. But within minutes the demon is raging again. My heart aches for her, but I have to know.
“Did you throw up today?” I ask, interrupting the flow.
She glares. “That’s all you care about, what I eat and whether I throw up!” she shouts. “You don’t care how I feel!”
I do care about her feelings, of course I do. But what I really care about is getting her well as fast as possible. Getting her through this nightmare.
I hate the demon. I fantasize about strangling it with my bare hands, squeezing until its forked tongue protrudes. But I can’t picture that without also picturing my hands around my daughter’s neck, because the demon wears her face and speaks with her voice.
Kitty cries until she falls asleep at one o’clock in the afternoon. Clearly she’s not going back to school today. When she wakes up an hour later, she’s a bit calmer. I sit with her as she drinks her milk shake, and eventually I ask, again, whether she threw up.
The look she gives me now is weary. “I tried,” she confesses. “I wanted to. I went into the bathroom and stuck my finger down my throat. But I couldn’t do it.”
I’m not religious, but I send a prayer toward the ceiling. Thank you, whoever and whatever. Thank you for watching over my daughter.


One of the strangest things about this whole year is that despite all the trauma and drama, I have a hard time remembering that Kitty’s ill. When she smiles or makes a joke, when I see a bit of the old Kitty, it’s as if I suddenly mistrust the events of the last few months. Things can’t be that bad. Can they? I’m a pessimist, the first to leap to the worst possible scenario; my lack of sunny positivity is a family joke. Yet these days I often find myself wondering whether we’re making a big deal out of nothing. It’s not denial; three months ago I was in denial. I know without question now that Kitty has anorexia, that her life was and still is in danger. And yet every time the demon emerges I’m surprised. I thought we were past all that. It’s as if my own thinking has been compromised by Kitty’s illness. As if I’ve caught a touch of anorexia myself.
If I look beyond what I want to see, I can easily chart the rise and fall of Kitty’s distress. It jumps when she’s stressed—like now, starting ninth grade in a new school—and when we hold the line around eating. It’s as if the illness is a wild animal, snarling, backing slowly into a corner. Its outbursts are a sign of resistance. We didn’t see the demon until we started refeeding her. In a way, it’s a measure of our effectiveness.
For instance, the night after Kitty tries to make herself vomit at school is a bad one. We get dinner into her, and a bite or two of the bedtime snack, but then we give up. Jamie stays in her room, holding on to her, keeping her safe as she rages and cries, while I put Emma to bed.
Emma’s room is dark and quiet, with two closed doors between her and Kitty’s radiating misery. Yet I know Emma is hyperconscious of the drama playing out across the hall. I sit beside her on the bed, as I’ve done every night since she was a toddler. This is our talking time, in the dark, just the two of us. I want to help her process what’s happening, but I don’t want to make everything revolve around Kitty. So I try to follow her lead.
Tonight she wants to talk about the anorexia. “Is Kitty going to get better?” she asks.
“Yes,” I promise, hoping it’s true.
“Are you taking care of her?”
Will you take care of me? That’s what I hear in Emma’s anxious question. “Always and forever,” I say.
We sit quietly for a few minutes. Then Emma says, “I can see the anorexia in my mind. It’s like a cartoon person, but it’s not funny.”
“No,” I say. “It’s not funny.”
“It’s wearing all black and has spiky hair.”
“Blond hair, like Kitty?”
“No, dark hair,” she says. And suddenly I can picture it too, faceless. A walking black hole that sucks everything into its open, aching mouth. Including a lot of Emma’s life.
My only consolation is that maybe watching Kitty go through this will somehow inoculate Emma against the possibility of an eating disorder. Craig Johnson, who directs the eating disorders unit at Laureate Psychiatric Hospital in Tulsa, Oklahoma, says that having a family member with anorexia nervosa makes a child twelve times more likely to develop it herself. In relative terms, the risk is still small, since only about 1 percent of girls and women develop the disease. But any extra risk is too much for me. I’ve heard of families with two anorexic daughters; a mother named Mary Ellen Clausen, who lives in central New York, started a nonprofit called Ophelia’s Place after both of her daughters struggled with anorexia. I can’t imagine what she’s gone through—what their whole family has gone through. Then again, before anorexia, I could never have imagined what Kitty’s going through now.
Back then, I wouldn’t have thought it important to understand the inner reality of an eating disorder. People suffer in so many ways—it’s not possible to get them all. Anorexia, I would have said, is one of many illnesses, and thank God it hasn’t happened to my family.
I don’t feel that way anymore, of course, because it has happened to my family. But self-interest is only part of the urge I feel to make people get it, give them a taste of what it’s like to have anorexia. Only a small subset of the population is biologically predisposed to have an eating disorder. But we’re all vulnerable in some way. I’ve had panic disorder for as long as I can remember, and the experience has shaped me profoundly. I’ve watched friends struggle with depression, bipolar disorder, anxiety disorder—the kinds of illnesses we all think happen only to other people. Advocates for mental health parity say that for every piece of parity legislation that’s been introduced, there’s a legislator with a spouse, a family member, or a close friend who struggles with some form of mental illness. We don’t get it until it gets us. But one way or another, it gets us all.
The next day, I take Kitty for her weekly weigh-in. Dr. Beth schedules us as her last appointment of the day, and she often stays to talk with us long past closing time. As usual, Kitty’s anxiety rises as the afternoon wears on. Getting weighed for her is a no-win situation. The demon wants her to lose weight, or at least not gain; the part of her that’s separate from the anorexia wants to gain weight, both because she wants to please us and because she wants to get better. “I want my life back,” is how she puts it. “I have no life now.” If she doesn’t gain weight, she suffers our disappointment, and her own. If she does, she suffers a cascade of anorexic thoughts and feelings, the wrath of the demon.
At the office, the nurse hands Kitty a cup and ushers her into the bathroom for the usual ritual. Then comes the moment of truth, when Kitty steps onto the scale, her back to the machinery, and waits for the nurse to nudge the metal weights into perfect alignment. I try to keep my face blank, though Kitty says she can always tell by looking at me whether she’s gained or not.
Today the scale shows neither gain nor loss. My heart sinks, even though I know that metabolism is complicated and weight gain is not a linear process. But I need to feel like Kitty’s moving forward, even at a glacial pace. Plus, some days I’m overwhelmed by the feeling of being way out here on our own. It’s not just that no one is telling us exactly what to do, that we’re more or less feeling our way through the dark and scary forest; we’re actually going against the conventional wisdom. If we’d taken the accepted route, Kitty would be an inpatient now at a hospital an hour away. Instinct tells me that that wouldn’t help her, that in fact it would harm her. But Jamie and I don’t know what the hell we’re doing. I’m not a doctor. What if my judgment is compromised? What if I’m just wrong?
Dr. Beth comes in with her usual smile. Tucking a strand of blond hair behind one ear, she looks over Kitty’s chart and reassures me that by every objective measure, Kitty is improving. Her heart rate’s up into the 70s; her pulse and blood pressure are good. Despite today’s stagnant scale reading, Kitty has gained fourteen pounds in the last seven weeks.
We talk about Kitty’s increasing anxiety, some of which is likely a by-product of refeeding. The psychiatrist bumped up Kitty’s dose of fluoxetine a few weeks ago, because she was feeling more anxious, and now Dr. Beth wonders if the meds are part of the problem. “Try cutting back to the previous dose,” she suggests—good advice that I suspect would never have come from the psychiatrist. In fact, as I later learn, study after study shows that antidepressants like fluoxetine don’t help people with anorexia. Which doesn’t stop psychiatrists from prescribing them.
Dr. Beth makes me feel like we’re doing OK. So many of the doctors and therapists we’ve seen since this began have exuded some level of blame or anger or annoyance—toward us and toward Kitty. Even when their words are neutral—Anorexia is no one’s fault, it’s a biological illness—their body language, the look in their eyes, convey a subtle sense of criticism. It strikes me that both doctors and ordinary people project all kinds of judgments, feelings, and desires onto people with eating disorders. Since getting sick Kitty has been both admired and scorned for her perceived stubbornness, envied for her emaciation, belittled for her feelings. The praise she’s received for her extreme thinness comes with a dollop of prurience, a sense that she’s accomplished something both meaningful and shameful.
I don’t believe anorexia is a response to environment, but I do wonder about its relationship with culture. Once you develop anorexia you become not just a person with an illness; you come to represent something here and now, in this time and place. You become the anorexic, your identity inextricable from the illness. Other diseases have carried a sense of stigma and judgment over the years—cancer, for instance, which was rarely mentioned or discussed when I was growing up. People with cancer felt a sense of shame and isolation, as if they were to blame for their illness.
But the stigma of anorexia, bulimia, and other mental illnesses goes beyond that. Even the way we talk about them is different. People with eating disorders lose their identity; they become anorexics or bulimics. We conflate them with the disease, as if whoever they were before the illness disappears when they’re diagnosed. Whereas there’s no one word to define someone with cancer or heart disease. A patient with lymphoma isn’t a lymphatic; he or she retains a sense of individual identity. It’s a small point, but it matters, because language shapes the way we think about the world. Calling someone “an anorexic” suggests that anorexia is all there is to her, that it is her and always will be, that there is no extricating the person from the disease.
Sometimes, while Kitty is at school or asleep, I take out our photo albums, filling my eyes with her face and body and essence before: Age eleven, standing in front of Lake Superior, pants rolled up, beside Emma, each of them holding up handfuls of rocks collected along the beach. Age three, on the dock of the house we rented in northern Wisconsin that summer, grinning beside her friend Cinda, a bulky orange life preserver around each of their necks. Age four, holding a newborn Emma, her blond hair falling protectively over the baby in her lap. Age nine, sitting at my mother-in-law’s kitchen table, totally focused on a stack of homemade pancakes.
I won’t mistake the disease for my daughter. I will remember Kitty as she was before anorexia and as she will be again when it’s gone.
I know I’m hypersensitive about this. What I want is for people to treat Kitty as though she’s not just another anorexic, one of the thousands who say the same things and look the same way and struggle with the same compulsions. I want people to see the girl beyond the disease, with her habits and charms and failings. Her idiosyncrasies, not anorexia’s.
But Kitty seems to feel relief at meeting other kids with eating disorders. She comes home from Ms. Susan’s first lunch group practically gushing. “No offense, but you guys don’t know what it’s like,” she tells me. “Mom, they really get it.”
I’m standing at the kitchen counter, scooping H?agen-Dazs into the milk-shake maker a friend sent over. “Honey, I’m so glad,” I tell her.
Kitty leans against the doorjamb, staying outside the kitchen as I prepare her food. “They totally get it,” she repeats. “I can be myself around them.”
I want to ask, Which self? But I’m afraid of what she might say, or imply. I don’t want her to take on the identity of anorexic. Maybe it’s inevitable. Maybe, in fact, it’s already happened, and I’m trying to close the barn door after the horse has galloped off. Still, one of the reasons I look forward to our appointments with Dr. Beth is that she seems to see beyond the disease. She talks to my daughter as if Kitty is an ordinary teenager. She asks about school and friends, boyfriends and movies. She brings a feeling of joy into the exam room, the joy of ordinary life, which we all have been missing for months.
Over the next few days, Kitty brightens visibly. Maybe cutting back on the meds helped. Maybe it’s the new lunch group. Or maybe it’s the weight gain. She seems engaged with the world in a new way. Or, rather, an old way, one we haven’t seen since last winter. She tells me she’s going to join Latin Club; Latin’s her favorite class, because she loves the teacher.
A few days later, as I walk Kitty up the hill to school, I ask, “How was Latin Club yesterday?”
Silence. Then she says, “I didn’t go.”
“Why not?”
Her eyes fill with tears. “Because they serve brownies at the meetings,” she says. “And I would want one, but I’d be afraid.”
“Afraid of what?” I think I know the answer, but I want to hear what Kitty says. Sometimes she seems incredibly unaware of how she’s feeling and acting. I wonder how she sees things in moments like this, when the demon has subsided below the surface.
“If I choose to eat something I don’t have to, then I’m bad,” she explains. If I choose to eat something I don’t have to. Anorexia is a prison sentence for a crime you didn’t commit, a crime that fills you nevertheless with guilt and dread.
I look at Kitty, pride and sorrow welling up in my heart. Sorrow over the claustrophobic, obsessive world she inhabits, and pride at her astonishing candor. These dispatches from the land of anorexia take a kind of bravery few people understand.
“You could go to the meeting and not eat anything,” I say, but she shakes her head, and I understand: Not yet.
The next day I get another lesson in just how hard things are for my daughter, when we go downtown to do errands. As we walk by a new Ben & Jerry’s store, she says, “If I were required to have another snack today, I would want to have it in here.”
I open my mouth to say “What?” and then close it again. I pick up on her cue. “You know, I’ve been reviewing your day’s calories, and you need an extra snack this afternoon,” I tell her.
I expect her to say no, despite the invitation she’s extended. Instead, she pushes open the door and goes inside, where she spends five minutes deliberating about what to eat—not freaking out, not panicking, but deciding what she’s in the mood for.
I have a good idea of how many calories Kitty’s eating every day—between twenty-five hundred and three thousand—and so far today she’s on track. I’m astounded by the fact that the harsh taskmaster that flays her with guilt and fear and misery could be rendered harmless by such a transparent charade.
But this charade only strengthens my instinct that Jamie and I are at war with the voice in Kitty’s head, the one that tells her not to eat, that she’s fat, that she’s loathsome and worthless. We hear only a fraction of its awful words, but Kitty gets up with it in the morning and goes to sleep with it drumming in her ears. We sit in Ben & Jerry’s and I watch her dip her wooden spoon again and again into a dish of frozen yogurt. Her face is open and unguarded and, yes, happy. I’m struck by the power of words—in this case, my words, which have rendered the voice in Kitty’s head mute and harmless. For the moment.
And I am amazed and grateful that this is so. All my life I’ve heard people say that love is powerful. This is the first time I deeply, truly believe it. Love can overcome the demon—for the moment. I know it will come back, in ten minutes or an hour or a day. The demon’s voice will roar in Kitty’s ears and spew out of her mouth and nothing we say or do right then will make it stop. But there will be other moments like this one, when our voices drown its insidious refrain. More and more moments, I hope, until, like the Wicked Witch of the West, the demon melts away.
I know that time is a long way off. I know the trouble is still now and the happy ending is yet to come. Earlier today I saw my doctor for a physical. When she walked into the room, I surprised both of us by bursting into tears. It felt good to cry; these days I am mostly numb and disconnected. I can’t afford to feel pain because once it starts it might never stop, and then what good would I be to anyone? There will be plenty of time to process all this later. After Kitty’s recovered. When, not if.
In fairy tales there is often a cleansing ritual, a symbolic expunging of dangerous magic. I want there to be a ritual for us. I want to walk through the house with a bundle of burning sage, a braided candle, a stick of incense. I want to wipe away the confusion and misery and suffering. But for rituals to work, you have to believe in them. And I don’t. I believe in the marriage between the mind and the body, thought and feeling. I believe in the body’s need to be nourished and the mind’s ambivalence about doing it. I can’t afford to feel powerless and helpless; that’s a luxury, that kind of thinking, and it won’t help Kitty one bit.
That night I sit with Kitty as she gets ready for sleep. Six months ago she would say goodnight and close her door, and that was that. Since the anorexia, we’ve resurrected our old bedtime routines. Now she lies on her stomach and hikes up her pajama top, and I put my hand against her back. I can still see the knotted rope of her spine, but now the vertebrae are covered with smooth flesh. Three months ago, I hated feeling the rude skeleton protruding through her icy skin. The claws of her hands. Touching her left me bruised and anxious.
With the tip of my index finger I trace letters against the warm skin of her back: I. L. O. V. E. Y. O. U. We started this ritual when she was learning to read, when putting letters together into words was a magic act she never tired of.
After a while I get up. “Don’t go,” says Kitty. “Don’t leave me all alone.”
“I won’t,” I say, easing myself down on the bed again. “You know I won’t.”


By the third week of September, Kitty’s weight has plateaued. Jamie and I confer with Ms. Susan and raise her calories to thirty-five hundred a day. That’s a lot of food.
Eating large amounts upsets Kitty’s stomach—eating any amount seems to upset her stomach, actually—so we try to reduce the volume and make sure everything she eats is calorie efficient. Our kitchen becomes High-Calorie Central; Paula Deen is my new literary muse. We go through so many sticks of butter that I dream about unwrapping them in my sleep, peeling back the translucent paper, dropping them one by one into an enormous metal bowl.
Which leaves Kitty with a meal plan something like this:
Breakfast: a large bowl of nutty granola mixed with vanilla yogurt and raspberry jam
Snack: a high-calorie protein bar
Lunch: a large sesame bagel slathered with 3 to 4 tablespoons of almond butter; chips; a piece of fruit
Snack: a milk shake made with 2 cups of H?agen-Dazs ice cream and a little milk
Dinner: a large serving of whatever we’re having; bread and butter; milk
Snack: three or four pieces of toast, buttered and sprinkled with cinnamon sugar; or a large (4 to a pan instead of 12) pumpkin chocolate chip or banana nut muffin
One of the challenges in refeeding Kitty is the fact that she feels no hunger. So she says, and I believe it. It’s still there—coming out in her continuous and obsessive thoughts about food, her need to plan every bite—but her brain and her body have become disconnected when it comes to eating, which makes sense in a way. If starvation is a function of, say, famine or war, if there’s no food available, then constant hunger pangs would be a pointless torment. Loss of appetite, in that case, is both a blessing and a self-defense mechanism.
Hunger is a function of a complex set of chemical interactions we don’t yet understand, involving hormones like ghrelin, which is produced in the stomach and makes its way to the brain, rising before a meal to trigger eating. People with acute anorexia have high levels of ghrelin. Another hormone connected with hunger is leptin, made by fat cells, which tells the brain you’ve eaten enough, shutting down hunger. People who have lost weight have low levels of leptin, which pushes them to eat more.
We need hunger in the same way we need pain: a stimulus that makes us behave in ways that preserve ourselves and our species. Without hunger, eating is a chore dictated by the clock, a literally unpalatable task to check off a list. Eating without hunger can feel punitive, the introduction of foreign matter into a body that does not welcome it. It’s easy to forget to eat without the relentless goad of stomach pangs, when food doesn’t look or smell good.
And hunger does more than just get us to the table. It determines, in part, how we metabolize what we eat. In the late 1970s, Swedish researchers fed two groups of women—one Swedish and one Thai—a spicy Thai meal. The Swedish women absorbed only about half as much iron from the meal as the Thai women. When the meal was mushed up and served as a paste, the Thai women absorbed 70 percent less iron than they had before—from the same food.*
The researchers concluded that when we eat a meal that’s unfamiliar or unappetizing, we don’t get as much nutrition out of it as we otherwise might. Why? Because some of the digestive and metabolic processes don’t take place in the gut. The smells, looks, and sensory gestalt of a meal we’re looking forward to trigger a series of processes in the brain, which in turn tells the salivary glands to kick into high gear, producing more saliva, and the stomach to secrete more gastric juices, both of which help digest the food.
Maybe this explains, in part, why it’s so hard for Kitty to gain weight. Maybe refeeding is not just a matter of calories in, calories out; maybe the anticipation and experience of eating helps determine how much of the meal Kitty’s body hangs on to. In which case this process is going to take a long time.
Physically, Kitty is making progress. Slow progress, but still. Mentally—that’s another story. At Dr. Newbie’s urging we start her on Zyprexa, a new-generation antipsychotic, and after two days she perks up, acting like herself again, with a certain alertness and outward-looking perspective that’s been gone for months. She says she feels better too, that she still has all the anorexia thoughts but the guilt isn’t as strong. Unfortunately, she develops a side effect called akathisia—jitteriness, agitation, and anxiety—and Dr. Newbie says we have to take her off the Zyprexa, that the anxiety will intensify to unbearable levels. When I tell Kitty, she protests, “But it makes the voice get quieter.” The voice in her head, she means. The voice of the demon.
I’m frustrated enough to cry. This is the only medical intervention that’s helped Kitty at all, and now she can’t take it. No shortcuts; we’ll have to do this the hard way.
When I look back even a month, though, I see how far Kitty’s come. Dr. Beth agrees. At our weekly appointment, Kitty asks when she can stop trying to gain weight and go on a maintenance diet, and Dr. Beth says, “Now!” When she heads down the hall to get something, I follow her out.
“I thought Kitty had to gain another ten pounds or so to reach her target weight,” I say.
“I think she can gain weight more slowly now,” says Dr. Beth. “Maybe a quarter pound a week.”
A quarter pound a week? I think about how long it took to get Kitty started gaining weight. I don’t understand why Dr. Beth wants us to slow down now that she’s actually got some momentum. Why go back to prolonging the misery?
“I’ve seen people overshoot their goal, and that wouldn’t be good,” she explains.
I want to ask, “Why not?” But I’m conscious, suddenly, of the fact that I weigh thirty pounds more than the charts say I should. Self-conscious. I don’t want to hear Dr. Beth say, “Because I don’t want her to be fat like you.”
To be fair, I have no idea if that’s what she’s thinking. What I’m thinking is, Wouldn’t it be better for Kitty to be a little “over”—whatever that means—than to chance falling down the rabbit hole again? We know the risks of her weighing too little; what, exactly, are the risks of her weighing five pounds “extra”?
I don’t say any of this, partly because I feel such self-consciousness. Instead, I tell Dr. Beth that I think Kitty heard the words “You don’t have to gain any more weight” and ask her to clarify. When we go back into the room, Dr. Beth tells Kitty she can up her activity level a bit and stay at the same calorie count. “So your weight gain will slow down,” she says. This is still a mixed message; for the last month we’ve been telling Kitty that she’s going to feel better when she’s gained enough weight, that our goal is to get her there as quickly as is practical and possible. We’ve told her to hang on, that things are going to get better. Now she’s hearing, more or less, this is it. This is as good as it’s going to get. I see the ambivalence on her face: the anorexia thinks this is fabulous news—you can stay thin! The part of Kitty that’s not thinking like an anorexic is not so sure this is a good idea.
I’m with her.
This will happen again and again over the course of the next seven months: not just Dr. Beth but Dr. Newbie and every doctor we see will be quick to tell Kitty that she can back off, not gain any more weight, based on the numbers on the chart. No one asks whether she still has anorexic thoughts and feelings. No one asks us what her behavior’s like, how hard it is for her to eat. They tell her she’s fine when we can see clearly that she’s not.
Once more I think of Daniel le Grange’s comment about how anorexia seems to infect everyone around the sufferer too. And I can’t help but wonder how much the current angst about obesity and the general culture of fatphobia affects doctors’ attitudes. Still, we’re lucky to have our treatment team, even if I don’t agree with everything they recommend. Today, for instance, toward the end of this appointment, Kitty asks if she can fast on Yom Kippur, two weeks away. I hold my breath, wondering what Dr. Beth will say.
What she says is just right: “That would not be a good idea for you, Kitty.”
“But all my friends will fast, and I’ll feel awful if I don’t,” says Kitty. “How about if I just eat lightly?”
“Nope,” says Dr. Beth. Thank God.
In the end, the nagging sense of unease I have about Kitty’s target weight is resolved in the best possible way: she begins to grow. By the end of September she’s half an inch taller, which means her target weight goes up too. For the moment, anyway, we’re back to straightforward refeeding. Spare no calories. Full steam ahead.